Costosternal Anatomy

The thoracic wall.

Keywords; costosternal anatomy, breastbone pain, rib treatment, Tietzes syndrome.

This area is unique in the body, and quite different to the other bones and joints. This is because of its important function of protecting of the vital organs, whilst still enabling breathing. The ribs make up an important part of the thoracic wall.

The ribcage is formed by three sets of bones:

  1. The sternum, or breastbone, in front,
  2. which connects via twelve pairs of ribs to
  3. twelve thoracic vertebrae posteriorly.

The joints between the breastbone and the ribs are made up of special so called costal cartilage which may sometimes become a very painful condition called Tietzes syndrome, or breastbone pain.

Note the costal cartilages arrowed in blue below.

Costosternal Anatomy


From the chiropractic perspective, costosternal anatomy is concerned with bones, muscles, joints and nerves. Of course there are also arteries ...

The spaces between the ribs are filled by the INTERCOSTAL MUSCLES. These muscles extends from the sternum to the angle of the rib, posteriorly. They are very important in breathing.

The PECTORALIS MAJOR muscle is can be seen on the anterior thoracic wall. It has two origins, one of which is the sternocostal cartilages and the other the sternum bone.

The PECTORALIS MINOR muscle is located at a deeper level than the pectoralis major muscle. It originates from the third, fourth and fifth ribs and is inserted in the coracoid process of the scapula.

The SERRATUS ANTERIOR muscle covers most of the lateral thoracic wall and originates from the first nine ribs. Its fibers converge posteriorly to be inserted into the medial margin of the scapula, thus contributing towards forming the medial wall of the axilla.

The diminutive SUBCLAVIUS muscle originates from the first rib, close to the chondrocostal junction, to be inserted in the collarbone. Its function is to stabilize the clavicle in movements of the shoulder.

The SERRATUS ANTERIOR muscle covers most of the lateral thoracic wall and originates from the first nine ribs. Its fibers converge posteriorly to be inserted into the medial margin of the scapula, thus contributing towards forming the medial wall of the axilla.

The diminutive SUBCLAVIUS muscle originates from the first rib, close to the chondrocostal junction, to be inserted in the collarbone. Its function is to stabilize the clavicle in movements of the shoulder.

Tietzes syndrome

Breastbone pain can be very severe.

Costo sternal joints: Breastbone Pain

These costosternal anatomy joints, when subluxated, are a common cause of chest pain. Chiropractic treatment involves stretching the doctor's hands right around the ribcage, from the sternum to the spine, an providing gentle thrusts to release the fixations.

The rib forms three synovial facet articulations with the spine;

  • One with the transverse process, the so called costo transverse joint, and
  • Two with the vertebral bodies above and below the rib, the so called costo vertebral joints.

This arrangement restrains the motion of the ribs allowing them to work in a parallel fashion during breathing. If a rib had only one joint posteriorly, the resultant swivel action would allow a rib to move out of sinc with respect to its neighboring ribs, making for a very inefficient respiratory mechanism.

These joints may be sprained, often after a violent sneeze, causing severe sharp pain with every breath. The condition responds extremely well to a gentle chiropractic adjustment.

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FROM THE COAL FACE : Iatrogenic Illness

The thoracic spine is usually not the source of serious problems. Irritating, and occasionally acute pain, but because of the stabilising ribs, it generally gives much less serious trouble than the neck and lower back. Consequently, it also less xrayed. Chiropractors generally, myself included will often adjust the thoracic spine without first having given it the attention that one might give the lumbar spine.

Mrs S is a woman of about thirty who had significant Low Back Pain since shortly after the birth of her first child, about three years ago.

Opinion has it that much low back pain starts during the last trimester, but in my experience it often starts soon AFTER the birth of the child. All the lifting, but sometimes within a month of falling pregnant.

The lower back pain didn't improve with various other medical ministrations, and six months the pain started radiating down her leg.

She has responded very well, and after a month her low back and leg pain is almost gone.

But I adjusted a subluxation between her shoulder blades, where she had no pain, and she is now really suffering. It's a little better, but she's not a happy lady. She came with one pain, and left with another.

That's what we call Iatrogenic Illness, or doctor caused disease.


UPDATE: Fortunately with the correct management of her rib the pain soon passed. My point? Rib pain can be caused by an overly zealous manipulation in the mid back.

For information about chiropractic treatment of rib pain, click here; RIB PAIN TREATMENT

Costosternal Anatomy - The Breast

The breast obviously lies just adjacent to the costo-sternal joints, and covers some of the muscles.

A breast condition may mimic the costo-sternal syndrome, and occasionally a breast examination by your chiropractor may be indicated. Alternatively, you could ask that your GP do the examination. Talk frankly about it.

During the treatment of the costo-chondral syndrome, the doctor's hands will approximate the breast tissue as s/he firmly adjusts the rib during the in or out phase of breathing. He should release his grip, and slightly remove his hands during the inactive phase of breathing, to ensure that there is no embarrassment.

Should you feel awkward then it may be necessary to ask a friend or family member to accompany you for breastbone pain treatment, or ask if the secretary may be present. It is best to talk frankly about it.

Nerves - costo sternal anatomy

The NERVE bundles from the spine, are threaded between the muscle layers, and are responsible for the innervation of the intercostal muscules.

The pain often radiates along the length of the rib causing flank pain (under the armpit), chest pain mimicing a heart attack if it's on the left side and, if it involves the lower ribs on the right, gallbladder or liver conditions.

As can be seen the costosternal anatomy is unusual in both function and structure, making it vulnerable to various pain syndromes. Other conditions may mimic a rib problem. For example, should you also be experiencing indigestion, a hiatus hernia. INDIGESTION HEARTBURN ...

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Interesting challenges of the day

1. Mrs B has had one of the nastiest of conditions; vertigo caused by a disturbance in the inner ear. Falling repeatedly and vomiting she consulted her doctor but medication didn't help. After two sessions of the Epley manoeuvres she was 50 percent better. After two weeks she was 75 percent improved; no longer vomiting or falling. She's not enjoying the Brandt Daroff home exercises.

2. Mr S, a 48 year old man, has right low back pain, groin pain and a numb feeling in his lower leg when he sports. For six months he's been off football. He too has two problems; a very treatable lumbar facet syndrome and a very serious blocked artery in the groin; it's called intermittent claudication. Smokers beware.  

3. Mr S looks like the leaning tower of Pisa; he has a slipped disc at L5 making him lean towards the opposite side. It's called the postero lateral disc hernia; we'll fix it, but he has to stop for a week or two. Antalgias are serious so take them seriously. 

4. Mrs V too has two conditions; a chronic low grade sciatica giving her an ache in the right leg, and a threatening Morton's neuroma. She's glad I'm back in Holland; chiropractic fixed it before, and we'll fix it again. 

5. Mrs W is one of the lucky ones, says her doctor. I agree. He says only 40% of patients with lumbar stenosis have a successful operation. We fixed a nasty slipped disc three years ago, but it came back two years later; the surgeon did a fine job but she has a weak ankle now giving her subtalar joint pain; it's routine stuff. 

6. I myself had an acute exacerbation of a femoral nerve lesion last year. One immediate treatment of the new strain by my colleague has fixed the pain in the lower back, but there's some residual numbness in the lower leg; no soaring tomorrow alas.

7. This lady is a 86 year old woman with a 63 scoliosis. Chronic lower back has been her lot in life but she's well pleased with chiropractic and comes for chiropractic help once a month; some conditions you can never cure.

8. She is an 78 year old woman, is doing remarkably well with a bad sciatica. But over 200 pounds she is not losing weight; in fact, gaining despite my suggestions. She's high risk for a stroke. I have referred her to a dietician to crack the whip.

9. A 61 year old man with upper cervical pain yesterday; it's not severe but also not getting better of its own accord. He's afraid it may turn very acute as when I treated him three years ago. Since then it's been fine. 

10. A 64 year old woman has had scheuermanns disease; it's left her with a spinal kyphosis and chronic middorsal pain. She responds well to chiropractic treatment provides she come every six weeks or so for maintenance treatment.

11. Mrs C has been having severe headaches, and taking a lot of analgesics. It's a non complicated upper cervical facet syndrome, and she's doing well.

12. Mrs D, a middle aged woman with hip pain of one year duration, despite other treatment. Xrays reveal an impingement syndrome and early hip arthritis. There's much to be done.

13. Mr D, a 71 year old man, has a severe ache in the shoulder and midback since working above his head. Trapped nerve tests are negative but he has advanced degenerative joints of Luschka; after just two treatments he is 50 percent better. Can we reach 90?

And so the day goes; chiropractors shouldn't be treating the elderly most medical sites state but that's so much bunkum.

Have a problem that's not getting better? Looking for a different slant on your pain? Want to pose a question?

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